Implementing LGBTQ+ inclusive mental healthcare into practice — A rapid mixed-methods implementation context assessment of an Australian local health network

Introduction : A complex system of interrelated barriers across different levels of the mental health sector contribute to lesbian, gay, bisexual, trans, and queer (LGBTQ+) people experiencing significant mental health disparities compared to heterosexual and cisgender populations in Australia. With only a small number of LGBTQ + Australians accessing specialist LGBTQ + mental health services, addressing these barriers in mainstream services is crucial to health equity. Method : We used the Mi-PARIHS facilitation planning tool and rapid ethnography to conduct a convergent parallel mixed-methods context assessment of fourteen sites within an Australian Local Health Network’s mental health services, identifying barriers and facilitators to implementing a holistic LGBTQ + model of care. We present a novel analysis using techniques from complexity science exploring correlative interrelationships between barriers and facilitators across domains in the Mi-PARIHS data; subjecting these interrelationships to network-analytic techniques. Results : The small difference in mean Mi-PARIHS domain scores at different sites of the local health network ( H  = 17.596, p  = 0.0015, η ²   =  0.04), and the network analysis affirmed that implementing an LGBTQ + model of care requires a holistic approach. We developed an explanatory causal model (presented as a causal loop diagram) disentangling what is meant by “holistic”, explicitly proposing how these barriers and facilitators work to maintain the status quo both between and within i-PARIHS domains. Discussion : Our findings recommend: 1) Healthcare leaders need clearly articulate support of LGBTQ + people and their care , as this is crucial for health care workers understanding how LGBTQ + care aligns with their organisation’s values and priorities and — therefore — feeling confident enacting this care; 2) The importance of time , for implementing change and for fostering LGBTQ + clinical champions; and 3) The importance of clearly articulated evidence for, trustworthiness of, and advantages appropriate LGBTQ + care presents for health services in implementation facilitation. We discuss how the novel, complexity science-derived analysis presented in this paper allowed us to operationalise our conception of “holistic” to specific, actionable targets for facilitation. We strongly encourage the use of complexity science techniques in i-PARIHS-driven implementation research as a means of decomposing notional “context-driven” or “holistic” approaches into concrete, operationalised targets for facilitation.